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Topics in

PAIN MANAGEMENT
Vol. 24, No. 5 Current Concepts and Treatment Strategies December 2008

CME ARTICLE
Pain Management for Occipital Neuralgia
Clifford Gevirtz, MD, MPH
Learning Objectives: After reading this article, the practitioner should be able to:
1. Describe two possible causes of occipital neuralgia.
2. Describe three possible therapeutic interventions in patients with occipital neuralgia.
3. Explain the roles of neurosurgical intervention and peripheral nerve stimulation in patients with occipital neuralgia.

he earliest clinical reference to the condition we now
T recognize as occipital neuralgia (ON) was by Beruto
and Ramos in 1821.1 Numerous sporadic reports of this
condition and its treatment have appeared since then.2,3
Hammond and Danta3 published one of the best descrip-
tions of the syndrome’s clinical features in 1978. They
described patients with severe paroxysmal or continuous
pain in the distribution of the occipital nerve with localized
tenderness overlying the path of the nerve as it crosses the
superior nuchal line, altered sensation in the form of pares-
thesia or dysesthesia in the distribution of the nerve, and
marked relief of the symptoms by localized treatment such
as a diagnostic nerve block or occipital neurectomy.
More recently, the International Headache Society defined
ON as a paroxysmal, sharp pain in the distribution of the
In This Issue
CME Article: Pain Management for
Occipital Neuralgia . . . . . . . . . . . . . . . . . . . . . . . . . .1
Mirror Therapy Makes Phantom Limb
Pain Vanish . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
CME Quiz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
lesser or greater occipital nerve with associated paresthesia
or dysesthesia in the same region.4 Patients usually describe
tenderness over the affected nerve with persistent aching
between the paroxysms and temporary relief of the condi-
tion after local anesthetic block.
Anatomy
The anatomy of the greater and lesser occipital nerves
explains the etiology and treatment options for ON.
The greater occipital nerve is formed by the medial branch
of the dorsal ramus of C2 that runs between the posterior
Dr. Gevirtz is Clinical Associate Professor, Department of Anesthesiology,
Louisiana State University-New Orleans, LA, and Medical Director,
Somnia Pain Management, 627 West Street, Harrison, NY 10528; E-mail:
cliffgevirtzmd@yahoo.com.
Dr. Gevirtz has disclosed that he has no significant relationships
with or financial interests in any commercial organizations pertain-
ing to this educational activity.
Dr. Gevirtz also has disclosed that the use of gabapentin, pregabalin, and
botulinum toxin for treatment of occipital neuralgia as discussed in this
article has not been approved by the U.S. Food and Drug Administration.
All faculty and staff in a position to control the content of this CME
activity have disclosed that they have no financial relationships with,
or financial interests in, any commercial companies pertaining to this
educational activity.

News in Brief . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Lippincott CME Institute, Inc., has identified and resolved all faculty
and staff conflicts of interest regarding this educational activity.

The continuing education activity in Topics in Pain Management is intended for clinical and academic physicians
from the specialties of anesthesiology, neurology, psychiatry, physical and rehabilitative medicine, and neurosurgery
as well as residents in those fields and other practitioners interested in pain management.

1
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Topics in Pain Management December 2008

EDITOR arch of the atlas and lamina of the axis. The greater occipital
nerve ascends between the inferior oblique and the semi-
Clifford Gevirtz, MD, MPH*
Medical Director spinalis capitis muscles. It pierces the semispinalis capitis
Metro Pain Management muscle and the trapezius muscle (adjacent to their insertion
New Rochelle, NY into the occipital bone between the superior and inferior
Clinical Associate Professor nuchal lines) to run along the occipital artery.5 This nerve
Department of Anesthesiology receives some small fibers from the medial branch of the
Louisiana State University third dorsal cervical (C3) ramus after it pierces the trapezius.
New Orleans, LA
A minority of anatomists postulate that a small cutaneous
ASSOCIATE EDITOR branch of the suboccipital nerve (first cervical [C1] dorsal
Anne Haddad* ramus) will occasionally join the greater occipital nerve as
Baltimore, MD it accompanies the occipital artery. The greater occipital
EDITORIAL BOARD nerve frequently connects with the lesser occipital nerve,
E. Richard Blonsky, MD which arises from the cervical plexus (formed by the upper
Pain and Rehabilitation Clinic of Chicago, Chicago, IL four ventral cervical rami). In rare cases, a connection can
Michael DeRosayro, MD be observed between the greater occipital nerve and the
University of Michigan, Ann Arbor, MI
superficial auriculotemporal nerve.6
James Dexter, MD
University of Missouri, Columbia, MO The greater occipital nerve divides into several branches and
Kathy Dorsey supplies the skin of the back of the scalp as far forward as the
Chelsea Medical Center, Chelsea, MI vertex of the skull. Radiation of pain to the retro-orbital and
Claudio A. Feler, MD other facial regions is thought to be due to sensory connections
University of Tennessee, Memphis, TN
between the principal sensory nucleus of trigeminal nerve and
Kathleen M. Foley, MD
Memorial Sloan-Kettering Cancer Center, New York, NY
substantia gelatinosa of the upper cervical spinal cord via the
Alvin E. Lake III, PhD
nucleus of the spinal tract of the trigeminal nerve.7,8 These sen-
Michigan Head Pain and Neurological Institute, Ann Arbor, MI sory connections explain the frequent occurrence of ON with
Daniel Laskin, DDS, MS trigeminal neuralgia and the occurrence of retro-orbital pain.
Medical College of Virginia, Richmond, VA
Vildan Mullin, MD
The Structural Etiology of Occipital Neuralgia
University of Michigan, Ann Arbor, MI
Patients with ON may be divided into those with struc-
Paul M. Paris, MD
Center for Emergency Medicine, Pittsburgh, PA
tural causes and those with idiopathic causes. Structural
Alan Rapoport, MD
causes include:
New England Center for Headache, Stamford, CT
• Direct trauma to the greater or lesser occipital nerve;
Gary Ruoff, MD
West Side Family Medical Center, Kalamazoo, MI
Frederick Sheftell, MD Topics in Pain Management (ISSN 0882-5646) is published monthly by
New England Center for Headache, Stamford, CT Lippincott Williams & Wilkins, 16522 Hunters Green Parkway, Hagerstown,

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UCLA School of Medicine, Los Angeles, CA or company. Opinions expressed do not necessarily reflect the views of the Publisher, Editor,
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Topics in Pain Management
• Compression of the greater or lesser occipital nerve or the C2
or C3 nerve roots by degenerative cervical spine changes;
• Cervical disc disease; and
• Metastatic tumors affecting the C2 and C3 nerve roots.
The greater occipital nerve receives sensory fibers from the
C2 nerve root, and the lesser occipital nerve receives fibers
from the C2 and C3 nerve roots. Cervical spine changes
include spondylosis, arthritis of the upper cervical facet joints,
and thickening of the ligaments in that area (particularly the
C1–C4 levels).
Some cases of presumed ON may, in fact, be individual
C2 or C3 radiculopathies. Compression of the greater
occipital nerve is possible as it travels up the neck, passing
through the semispinalis and trapezius muscles. A case of
ON that follows a whiplash or hyperextension injury may
arise from this type of compression. Other possible causes
include localized infections or inflammation, gout, dia-
betes, and blood vessel inflammation.
Although the frequency has not been quantified, most
patients seen in pain clinics fall into the category of “unknown
cause” when no identifiable lesion is found.
Clinical Symptoms
ON symptoms include aching, burning, and throbbing
pain that often is unilateral and continuous with intermit-
tent shocking, shooting pain. The pain usually originates in
the suboccipital area and radiates to the posterior and/or lat-
eral scalp. Occasionally, patients report pain behind the eye
on the affected side. Pain also may be perceived over the
neck, temple, and frontal regions.
Pressure over the occipital nerves may amplify the pain, but
there usually is no clear trigger. Furthermore, some patients
may have a positive Tinel’s sign over the course of either the
greater or the lesser occipital nerve. Occasionally, neck
movements (e.g., extension and rotation) may trigger pain.
At times, patients with ON may experience symptoms simi-
lar to those of migraine or even autonomic changes charac-
teristic of cluster headaches. Associated symptoms include
posterior scalp paresthesia, photophobia, and dizziness.
Many patients with ON report a cycle of pain-spasm-pain.
Diagnosis
Thorough history-taking and a complete physical and neu-
rologic examination are necessary in diagnosing any
headache syndrome. A diagnosis usually is based on the
characteristic affected area of the pain. Finding tender areas
that exacerbate the pain also suggests the diagnosis.
It is important to clarify whether the cause of ON is struc-
tural or idiopathic. Abnormal findings on neurologic exam-
ination usually indicate a structural cause, in which case CT
or MRI of the head and cervical spine may be indicated to
identify the exact structural lesion.
©2008 Lippincott Williams & Wilkins, 800-787-8981
December 2008
The workup of ON should include assessment for atlanto-
axial joint instability (i.e., assessment of rotation, extension,
and flexion of the neck). Patients with a history of rheuma-
toid arthritis or trauma should receive a thorough examina-
tion of the entire spine. Diagnostic occipital nerve blockade
also is very important in making a diagnosis. ON can easily
be confused with migraines and other headache syndromes.
In some cases, ON has been misdiagnosed as fibromyalgia,
cervical spine arthritis, or cervical disc disease.
Therapeutic Options
If the cause is structural, surgical treatment may be indi-
cated. Because most patients have no clear structural cause,
their treatment usually is symptomatic. Treatments that may
be considered include local nerve blocks, medications,
occipital nerve stimulator implantation, surgical decom-
pression, lesioning of the C2 and/or C3 nerve roots, or even
ablation of the peripheral branches of the greater and/or
lesser occipital nerves.
The management of ON usually starts with a conservative
regimen: trials of medications such as nonsteroidal anti-
inflammatory drugs, medications for neuropathic pain
(anticonvulsant medications, tricyclic antidepressants), and
possibly opioids.
Some cases of presumed ON may,
in fact, be individual C2 or C3
radiculopathies.
Conservative Treatment
Physical therapy, massage, acupuncture, and heat are other
treatments that have been reported in the literature for the
treatment of ON.
Medications
Medications that may help relieve pain in ON include
gabapentin 300–3600 mg/day (Neurontin; Pfizer), pregabalin
150–600 mg/day (Lyrica; Pfizer), and baclofen 40–120
mg/day (Kemstro, Lioresal; Lannett). However, clinical experi-
ence shows that while these may help in some cases, it is rare
that medication alone completely resolves the pain of ON.
Nerve Blocks
Occipital Nerve Block
Occipital nerve block is indicated for both the diagnosis
and treatment of ON. Percutaneous occipital nerve block
using a local anesthetic agent such as lidocaine—with or
without corticosteroids—is valuable for the diagnosis of
ON. This nerve block also nearly always provides immediate
pain relief—but with varying degrees of long-term success.9
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Topics in Pain Management
In one series of 92 patients treated with percutaneous lido-
caine and corticosteroid injection, improvement was seen in
87% of patients, with recurrence occurring in between 1
and 8 months in 31.5% of those with initial improvement.10
The greater occipital nerve is 2.5–3 cm lateral to the exter-
nal occipital protuberance and medial to the occipital artery.
This nerve is blocked slightly above the superior nuchal line,
just medial to the occipital artery, which is easily palpated.
After antiseptic preparation, a 25-gauge, 1-inch needle
attached to a 5-mL syringe is placed just medial to the artery
at the above location. For diagnostic indications, 1 mL of
local anesthetic is injected. For treatment injection, 3–5 mL
of local anesthetic is combined with a long-acting steroid
preparation. Anesthesia in the region of the greater occipital
nerve usually occurs within 5 minutes of injection. The
lesser occipital nerve can be blocked by fanning the needle
laterally and placing additional local anesthetic.
The most serious complication is piercing the occipital
artery, with resultant bleeding. If bleeding is evident, com-
pression of the artery for 5 full minutes usually avoids any
significant problems.
Permanent relief of symptoms in some patients after a sin-
gle injection of an occipital nerve block may be explained
by interruption of the cycle of pain, reflex muscle spasm,
and more pain. Unfortunately, permanent relief after a sin-
gle injection is uncommon.
C2 and/or C3 Ganglion Block
C2 and/or C3 dorsal root ganglion (DRG) block also has
been reported to be efficacious in treating some patients.
However, it is uncertain whether this is superior to the
superficial block approach. The major risk of DRG block is
intravascular injection into a radicular artery accompanying
the nerve root, the vertebral artery, or a total spinal from
intrathecal injection. Any of these complications could be
catastrophic compared with a peripheral nerve block.
However, repeat blocks with corticosteroids may have adverse
effects. A case report published in 200111 illustrated the severe
effects of excess corticosteroids. A 39-year-old woman who had
six bilateral greater occipital nerve blocks over a period of 3
months developed signs and symptoms of Cushing syndrome:
intermittent hypertension, severe muscle weakness, and fluid
retention. Hair loss over the injection site also has been reported.
Botulinum Toxin
Botulinum toxin (Botox; Elan) has been reported in several
case series12,13 to be effective in treating whiplash-associated
disorders that often cause ON. It improved the pain and
increased the range of motion in these patients. Because of
its success in the treatment of muscle spasms and cervical
dystonia, botulinum toxin may prove to be a reasonable
treatment option for ON if adequate studies are conducted.
This is an off-label use of the medication.
4 ©2008 Lippincott Williams & Wilkins, 800-787-8981
December 2008
Radiofrequency Thermocoagulation
Radiofrequency (RF) thermocoagulation is another widely
used method to treat ON. It has many advantages, including
safety, efficacy, a rapid recovery period, and no permanent
scarring. C2 ganglionostomy by RF lesion generator also
has resulted in significant pain relief. Pulsed RF is another
technique used to treat ON. In a case report, a patient
treated with pulsed RF was pain free after 12 months of fol-
low-up. However, large case series using this method in ON
have not been published.
Recently, a new surgical treatment was reported consisting
of neurolysis of the greater occipital nerve and sectioning
of the inferior oblique muscle.
Occipital Nerve Stimulator Implantation
Neurostimulation methods for control of chronic neuro-
pathic pain have recently gained in popularity. The reasons
for this are multifactorial. As opposed to nerve ablation,
these methods are minimally invasive and reversible.
Improvements in hardware design have simplified implan-
tation techniques and prolonged equipment longevity.
Stimulation trials have become less invasive, letting
patients test the effects before final implantation. Finally,
the scientific evidence has shown good outcomes of neu-
rostimulation methods for chronic neuropathic pain control.
Surgical implantation of a subcutaneous electrode along the
C1–C3 nerve level has been shown to significantly reduce the
pain of ON in patients who have failed conservative therapies.
In a study of 19 patients by Weiner and Reed, 14 95%
reported improvement in their quality of life and said they
would undergo the procedure again. With follow-up ranging
from 1.5–6 years, 12 patients reported good to excellent
response with greater than 50% pain control and a need for
little or no additional medications. The 13th patient was sub-
sequently explanted after symptom resolution.
The benefit of this procedure is that it is minimally inva-
sive and there is no permanent destruction of nerves or
other vital structures. Another advantage is that patients can
first undergo a percutaneous trial of temporary lead place-
ment for several days before conversion to permanent lead
implantation. Depending on the results of the temporary
percutaneous trial, patients may or may not undergo the
more-invasive permanent lead implantation.
It has been postulated that a successful temporary percuta-
neous lead trial, in combination with a previously docu-
mented successful diagnostic occipital nerve block, can
predict a highly effective permanent occipital nerve stimula-
tor implantation. Weiner and Reed concluded that in patients
with medically intractable ON who failed to experience relief
from conservative therapies, peripheral nerve electrostimula-
tion subcutaneously at the level of C2 appears to be a reason-
able alternative to more invasive surgical procedures.
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Topics in Pain Management
Surgical Intervention
Surgical Options
ON can occasionally be treated successfully with microvas-
cular nerve decompression. Other surgical procedures to con-
sider include epifascial electric stimulation, dorsal cervical
rhizotomy, neurolysis of the greater occipital nerve, and RF
rhizotomy. Selective C2 and/or C3 dorsal rhizotomy is another
option, although few papers have been published assessing its
utility. Dubuisson15 followed 14 patients over a period of 33
months after partial posterior rhizotomy at C1–C3. He found
that 10 of them (71%) had continuing significant relief.
Surgical Intervention After Nerve Block
Stojanovic16 retrospectively studied 17 patients with ON who
underwent a total of 32 CT fluoroscopy-guided C2 or C2 and
C3 nerve-root blocks as part of screening for potential surgery.
Of the 17 patients, nine had ON after prior neck or skull-
base surgeries. Patient ages ranged from 17–76 years (mean
age, 43). Eleven of the patients were female. All the
patients had refractory ON. Nine patients developed ON
after neck or cranial-base surgery for trigeminal neuralgia
(n = 4), retromastoid vestibular neurectomy (n = 2), resec-
tion of neck neuroma (n = 1), cervical diskectomy (n = 1),
or occipital osteoma resection (n = 1). Seven patients did
not have an identifiable cause of their ON, and in one
patient, it commenced after an automobile accident.
CT Fluoroscopy-Guided Nerve Block
All of these blocks were performed without anesthesia or
sedation. One patient underwent bilateral C2 and C3 nerve
root block. An axial scout CT from C1 to C3 without intra-
venous contrast material was performed in all patients.
Thereafter, the anticipated site of needle entry between
C1–C2 and C2–C3 was marked.
Needle placement for C2 block was between posterior
arches of C1 and C2, just behind the inferior aspect of the
lateral mass of C2.
For C3 block, needle placement was at the lateral aspect of the
C2–C3 foramen, just anterior to the base of C3 superior facet.
Using sterile technique, a 25-gauge, 5-inch spinal needle
(Becton Dickinson) was advanced medially under intermit-
tent CT fluoroscopy toward the C2 (or C3) nerve root.
After placement of the needle tip next to the expected loca-
tion of the exiting C2 (or C3) nerve root was confirmed,
connector tubing was attached to the spinal needle.
Approximately 2 mL of 0.25% bupivacaine was injected
after making sure that no blood was aspirated before injec-
tion. Injection of 1 mL of nonionic iodinated contrast mate-
rial (Optiray 350; Mallinckrodt) was performed in two
patients to document accurate placement of the needle tip.
The patient’s response to bupivacaine injection was docu-
mented. A positive response was considered complete relief
of pain with numbness in the distribution of the occipital
©2008 Lippincott Williams & Wilkins, 800-787-8981
December 2008
nerves. A negative response was considered persistence of
pain after the nerve block.
Stojanovic found that all patients had temporary relief of
symptoms after percutaneous CT-guided block and felt that
occipital numbness was an acceptable alternative to their pain.
On the basis of the positive results of the nerve blocks in
terms of temporary pain relief, all 17 patients underwent
unilateral (n = 16) or bilateral (n = 1) intradural C1 (n = 9),
C2 (n = 17), C3 (n = 17), or C4 (n = 7) dorsal rhizotomy.
All patients were followed up for assessment of pain relief
for a mean of 20 months (range, 5–37 months). Sixteen
patients were assessed for degree of satisfaction with and
functional state after surgery. One patient died 8 months after
rhizotomy of complications related to preexisting liver disease.
C2 and C3 rhizotomies were performed in isolation or in
combination with C1 or partial C4 rhizotomies. The num-
ber of levels depended on the presence of C1 dorsal rootlets
and access to upper C4 rootlets after C1, C2, and partial C3
laminectomies. All rhizotomies were performed by using
general anesthesia with the patient prone. The patients were
CT fluoroscopy-guided percutaneous
discharged home in 2–3 days.
C2 and/or C3 nerve block is useful as
an additional confirmation of ON and a
preoperative guide for dorsal cervical
rhizotomy.
Immediately after surgery, all patients had complete relief
from pain. At follow-up, 11 patients (64.7%) had complete
relief of symptoms, two (11.8%) had partial relief, and four
(23.5%) had no relief. Seven of eight patients (87.5%) with-
out prior surgery had complete relief of symptoms, and one
patient (12.5%) had partial relief, as opposed to complete
relief in four (44.4%) of nine, partial relief in one (11.2%) of
nine, and no relief in four (44.4%) of nine patients with a his-
tory of prior surgery. Because of the small number of patients,
this difference was not statistically significant (p = 0.110).
Eleven (68.8%) of 16 patients stated that the surgery was
worthwhile. Eight (50%) of 16 patients thought they were more
active and functional after surgery, whereas 25% said they were
either unchanged or less functional than before surgery. None
of the patients without a history of surgery reported a decreased
sense of functional activity after rhizotomy.
CT fluoroscopy-guided percutaneous C2 and/or C3 nerve
block also is useful as an additional confirmation of ON
and a preoperative guide for dorsal cervical rhizotomy.
Conclusion
ON is a headache syndrome that requires careful attention
for proper diagnosis and treatment. Typically, there is no
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Topics in Pain Management
clear structural cause, although appropriate workup should
be considered to rule out any pathologic structural causes.
The occipital nerve block is a valuable, simple, and safe
diagnostic and therapeutic tool that should be considered
early in the course of treatment.
If the pain persists despite preliminary therapies, including
occipital nerve blockade with local anesthetic and steroid, bot-
ulinum toxin or permanent implantation of a percutaneous
occipital nerve stimulator should be considered before CT-
guided nerve blocks and destructive C2 and/or C3 root surgi-
cal procedures are implemented. I
References
1. Beruto LJ, Ramos MM. Decades de med y cirug pract. Madrid
1821;3:145–169.
2. Martelletti P, Suijlekom HV. Cervicogenic headache: Practical
approaches to therapy. CNS Drugs 2004;11:793–805.
3. Hammond SR, Danta G. Occipital neuralgia. Clin Exp Neurol
1978;48:23–32.
4. Headache Classification Committee. The International
Classification of Headache Disorders, 2nd edition. Cephalalgia
2004;24:1–160.
5. Grant JCB. An Atlas of Anatomy, 6th ed. Baltimore: Williams &
Wilkins, MD plate 490.
6. Grant JCB. An Atlas of Anatomy, 6th ed. Baltimore: Williams &
Wilkins, MD plate 491.
Visualizing a Phantom Limb Makes Pain Vanish for Some Patients
Mirror Therapy Offers Relief for Amputees at Walter Reed
Magicians have used mirrors for centuries to fool the eye.
Now, a novel therapy uses a looking glass to foil one of
nature’s cruel tricks: real pain that feels as if it comes from
an amputated limb.
Mirror therapy, also called mirror-box therapy, is being
used at military hospitals such as Walter Reed Army
Medical Center in Washington, DC, and the National Naval
Medical Center in Bethesda, MD, to treat soldiers returning
from Iraq and Afghanistan who have lost a limb but still
feel its pain.
This therapy has had significant success in trials by physi-
cians including Jack W. Tsao, MD, DPhil, associate profes-
sor in the Department of Neurology at the Uniformed
Services University of the Health Sciences in Bethesda.1
Other prominent researchers investigating mirror therapy
include Lorimer Moseley, PhD, research fellow at Oxford
University, and Eric M. Altschuler, MD, clinical assistant pro-
fessor of neurological surgery at the University of Pittsburgh,
6 ©2008 Lippincott Williams & Wilkins, 800-787-8981
December 2008
7. Anthony M. Headache and the greater occipital nerve. Clin Neurol
Neurosurg 1992;94:297–301.
8. Trancredi A, Caputti F. Greater occipital neuralgia and arthrosis of
C1–C2 lateral joint. Eur J Neurol 2004;11:573–574.
9. Kuhn WF, Kuhn SC, Gilberstadt H. Occipital neuralgias: Clinical
recognition of a complicated headache: a case series and literature
review. J Orofac Pain 1997;11:158–165.
10. Gawel MJ, Rothbart PJ. Occipital nerve block in the management
of headache and cervical pain. Cephalalgia 1992;12:9–13.
11. Lavin PJ, Workman R. Cushing syndrome induced by serial occip-
ital nerve blocks containing corticosteroids. Headache 2001;41:
902–904.
12. Blumfeld AM, Dodick DW, Silberstein SD. Botulinum neurotoxin
for the treatment of migraine and other primary headache disor-
ders. Dermatol Clin 2004;22:167–175.
13. Freund BJ, Schwartz M. Use of botulinum toxin in chronic
whiplash-associated disorder. Clin J Pain 2002;18(6 Suppl):
S163–168.
14. Weiner RL, Reed KL. Peripheral neurostimulation for control of
intractable occipital neuralgia. Neuromodulation 2002;2:217–221.
15. Dubuisson D. Treatment of occipital neuralgia by partial posterior
rhizotomy at C1–3. J Neurosurg 1995;82:581–586.
16. Stojanovic MP. Stimulation methods for neuropathic pain control
Curr Pain Headache Rep 2001;5:130–137.
who is investigating the use of mirror therapy in rehabilitation
of stroke patients. Others are investigating its use for treating
complex regional pain syndrome (CRPS) type I.
“It doesn’t help everyone, but for the people it does help,
it’s very dramatic, and it appears to be curative,” Tsao said
in an interview with Topics in Pain Management. “Within
about a week, people report decreased pain, and for the uni-
lateral lower limb amputees in our study, we found it was
approximately a 50% decline.”
At the end of 4 weeks, most patients’ pain was barely
there, if at all.
At the very least, mirror therapy seems to do no harm to
those who try it, even if it doesn’t relieve their pain. “I have not
heard of anyone getting worse from mirror therapy,” Tsao said.
He has taught or administered the therapy to about 40
patients. “We offer it as one of the therapies they can try,”
Tsao said. “Fortunately, not everyone has phantom pain.”
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Topics in Pain Management
But it would be fair to say that almost everyone who has an
amputation experiences at least some phantom pain, as about
90% of the soldiers who undergo an amputation are affected.
Other military hospitals are starting to offer mirror therapy,
including Landstuhl Regional Medical Center, a major U.S.
Army hospital in Germany, Brooke Army Medical Center in
San Antonio, and the Naval Medical Center in San Diego.
No Special Equipment
Mirror therapy involves having a patient hold a mirror up
to himself or herself so that the reflecting side faces the
intact leg, and then move the intact limb while watching its
reflection in a mirror and simultaneously going through the
mental process that would move the phantom limb if it were
there. The mirror is positioned so that the reflection appears
to be the former limb (Figure 1).
With mirror therapy, Tsao said, “The patients have the
sensation that they are moving their phantom limb in the
same way as their intact limb.”
Although at least one commercial “mirror-box” is manu-
factured and sold in Great Britain for the equivalent of $40,
the mirrors used for the therapy Tsao carries out sell for
about $20 in the home section of any major retail store. The
instructions are so simple and straightforward that Tsao
sends them out in a four-slide PowerPoint presentation to
health care providers and amputees who request them.
First Described by Ramachandran
Mirror therapy was first described in the 1990s by Vilayanur
S. Ramachandran, MD, PhD, professor of neuroscience and
psychology at the University of California at San Diego, and
colleagues.2
They theorized that phantom limb pain is caused by a con-
flict between visual feedback and proprioceptive represen-
tations of the amputated limb.3
Since then, mirror therapy also has been tried with patients
recovering from strokes and with others dealing with pain from
CRPS type I, also known as reflex sympathetic dystrophy.
Mirror therapy got broad exposure over the summer when
an article in the June 30, 2008, issue of The New Yorker
described its use in treating refractory cases of pain and
even pathologic itching.
Attention to phantom limb pain never has been more
urgent. Compared with past military conflicts, technology
and medical advances now let medics save more soldiers’
lives even when they have suffered catastrophic injuries.
But many of these surviving soldiers have lost a leg or an
arm, leading some physicians to dub the current conflicts
the “War on Limbs.”
In fact, Tsao said, the fact that so many patients now are
coping with phantom limb pain from battlefield injuries is
precisely why he was able to conduct a clinical trial: Not
only are there more patients but the federal government
also provided research grants for the study.
©2008 Lippincott Williams & Wilkins, 800-787-8981
December 2008
Consequently, other amputees around the country are
beginning to have access to this therapy. “We’ve sent out
the instructions to people who have e-mailed us asking how
their patients can access it,” Tsao said.
How Mirror Therapy Works
He and his colleagues theorized that mirror therapy’s suc-
cess may be due to mirror neurons in the hemisphere of the
brain that is contralateral to the amputated limb. “These
neurons fire when a person either performs or observes
another person performing an action,” they wrote.
Tsao and his co-investigators conducted a randomized,
sham-controlled clinical trial at Walter Reed with patients
who had had a leg or foot amputated. Their results provide
strong evidence that mirror therapy reduced and sometimes
even cured phantom pain, and that the actual visualization
of the mirror image was critical. Nevertheless, there still is
much to be studied to understand better why it works and
which patients are more likely to benefit from it, Tsao said.
The instructions are so simple and
straightforward that Tsao sends them
out in a four-slide PowerPoint
presentation to health care providers
and amputees who request them.
Proxy Could Work for Double Amputees
Tsao already has begun to explore a way for double
amputees to benefit from mirror therapy. He sees some
promise in a sort of mirror therapy by proxy: A practitioner
sitting next to the patient moves a limb while the patient
watches the movement and tries to perform it.
“Unfortunately, we now have many double lower-limb
amputees, and for them, using a mirror to view the intact
limb isn’t an option,” Tsao said.
But if the whole idea of having a visual target is correct,
then watching someone else’s foot moving may be just as
good. The outcome of this investigation could shed more
light on the role of having a visual target, even if by proxy.
Functional MRI Could Provide a View
Tsao and colleagues at the National Institutes of Health
are planning to explore, using functional MRI (fMRI), what
parts of the brain are activated during mirror therapy.
For now, mirror therapy seems to work even if researchers
don’t know why. But fMRI could help better determine
which patients are most likely to benefit, Tsao said.
“If it doesn’t work with a patient, knowing more about the
why allows the clinicians to move on to another therapy
sooner, rather than later,” he said.
7
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Topics in Pain Management December 2008

Tsao and his colleagues are working on the theory that

phantom pain might be linked to proprioceptive memory.
“We believe it is possible that there is a retained memory of
the limb in the brain, [and this limb] is experiencing pain,” he
said. “Many amputees report the sensation that their phantom
limb is fixed or stuck in an uncomfortable position. Using the
mirror allows the patient to move the limb freely, thus wiping
out the memory of the limb being stuck and in pain.”
Tsao added: “We’re trying to work on that idea a little
more, plus we will be looking at medications that might
help those who aren’t helped by mirror therapy.”
In the meantime, there is no shortage of fascinating but
puzzling anecdotes related to mirror therapy.
“People have used the mirror to scratch an itch in the
phantom limb,” Tsao said, by scratching the corresponding
place on their intact limb.
Trial Uses Two Sham Therapies for
Control Groups
For the trial, he and his co-investigators randomly assigned
22 patients to the treatment group and to two control groups,
all of which practiced the therapy they were assigned for 15
minutes daily for 4 weeks under direct observation as follows:
Mirror Group. Patients in this group sat up in bed with
their leg(s) stretched out before them and a lightweight rec-
tangular mirror between the legs. They were asked to move
the intact foot and view the movement reflected in the mir-
ror for the 15 minutes. At the same time, they tried to per-
form the same movements with the amputated limb while
viewing the reflection of the intact limb in motion.
Covered-Mirror Group. This group of patients was asked
to straddle a mirror in the same way as the mirror group and
also move the intact foot or leg while watching the mirror.
However, the mirror’s reflecting surface was covered by an
opaque sheet that kept any reflection of the intact leg from
being seen. Patients in this group tried to move both the
intact and amputated limbs.
Visualization Group. These patients were trained in men-
tal visualization and asked to close their eyes and imagine
performing movements with their amputated limbs.
In all three groups, patients recorded the number, duration,
and severity of episodes of pain. The primary endpoint in
Tsao’s study was the severity of pain after 4 weeks of therapy,
compared with baseline scores. After four subjects dropped
out, six subjects in each group completed 4 weeks of therapy.
Although the baseline scores for all three groups were
similar, all the patients in the mirror group reported a
decrease in intensity, duration, and number of their pain
episodes. The median change, using a 100-mm visual ana-
log scale, was –24 mm. The range was –54 mm to –13 mm.
In contrast, only one patient (17%) in the covered-mirror
group reported a decrease in pain, and three patients (50%)
reported that their pain became worse.
Figure 1. The patient sits in bed straddling a mirror that reflects the
intact limb. (Courtesy of Jack Tsao, MD, DPhil.)
In the mental-visualization group, two patients (33%) reported
a decrease in pain, and four (67%) reported worsening pain.
At the end of the 4 weeks, the mirror group reported an aver-
age pain severity score of less than 10 mm, while the covered-
mirror group had a median score of more than 30 mm and the
visualization group had a median score of nearly 60 mm.
When the covered-mirror and visualization groups crossed
over to mirror therapy at the end of the initial 4 weeks,
eight of the nine patients whose pain had not decreased
(89%) reported less pain after 4 weeks of mirror therapy.
Their median scores declined steadily to approximately 15
mm. Meanwhile, as the mirror group continued for another
4 weeks, its pain severity scores continued to decrease to a
median of less than 5 mm.
Putting Mirror Therapy to the Test
After Ramachandran’s initial study, anecdotal evidence
was recorded for and against mirror therapy, and enough
interest developed that some commercial “mirror boxes”
were marketed.
“Since that time, we’ve seen reports that say mirror ther-
apy for phantom limb pain works, or doesn’t work,” Tsao
said. “Nobody had previously done a controlled study of
the therapy for phantom limb pain, specifically, until we put
it to the test at Walter Reed.
“What we wanted to do was to prove definitively whether
or not mirror therapy works, and if it worked, we wanted to
know which component—vision, moving the intact and
phantom feet, or just moving the phantom foot—was actu-
ally responsible for pain relief,” he said.
Hence, the visualization group and the covered mirror
group as control arms.
Why Cover the Mirror?
”The covered mirror group would move both intact and phan-
tom feet, thus removing visual feedback, which allowed us to

8 ©2008 Lippincott Williams & Wilkins, 800-787-8981

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Topics in Pain Management
test whether simply moving the intact foot simultaneously with
the phantom foot would allow pain relief,” Tsao said.
“Similarly, mental visualization removed any impact on
pain of moving the intact foot when subjects were asked
only to visualize moving the phantom foot. In this way, we
tested whether moving the phantom foot alone—in the
absence of either visual feedback or the intact foot mov-
ing—would be sufficient to allow pain relief,” he said.
“We offered patients who were in the covered mirror and
mental visualization groups the opportunity to try the mir-
ror therapy after their 4-week period, and most of them
improved after using mirror therapy,” Tsao said.
“Somehow, seeing the movement as well as trying to
move the phantom limb in the same way as what they are
seeing is actually the key to the therapy,” he said. “Now,
why that is, we have yet to fully understand. It does support
the idea of phantom pain being caused by a visuoproprio-
ceptive mismatch in the brain.”
Vision Clearly Is the Key
“If you think about reaching for a glass of wine, typically,
most people use vision to guide their hands to the target,
Researcher Addresses Questions About Study
In an article in Scientific American in April 2008, 1
Lorimer Moseley, PhD, a research fellow at Oxford
University, wrote of his own interest in the mirror effect on
phantom limb pain. He listed several questions he said
have not been answered that he would like to ask Chan et
al.2 about their study. Moseley wrote: “I think it is a pity
that this paper was a letter, because a letter’s need for
brevity meant that key information was left out.”1
We thought the questions Moseley raised were good
ones, so we asked the study’s corresponding author, Jack
Tsao, MD, DPhil, to answer them. Here are his responses:
Moseley asked: “What happened to the three who didn’t fin-
ish the study? Which group were they in? If they were all in the
mirror group, then the results would be far less convincing.”1
Tsao wrote to Topics in Pain Management in reply: “We
had four subjects drop out initially. Three subjects dropped
out after the first day and before we had any report back on
the effects of mirror therapy. The other subject was inconsis-
tent with participating in the mirror group, but his pain did
decrease. If the question is referring to the three subjects in
the covered mirror and mental visualization groups who did
not continue to cross over to mirror therapy, then the expla-
nation is that they did not want to continue to participate.”
Moseley asked: “To what question did the pain measure
relate? If it related to pain at the end of the 15 minutes,
then the study tells us about instantaneous effects. If it
©2008 Lippincott Williams & Wilkins, 800-787-8981
December 2008
which is the wine glass,” Tsao said. “If you’re blind, you
obviously use proprioception as the primary sense for your
concept of space in reaching the target.
“You can use vision and proprioception, but vision is
much more important than proprioception for most people.
We now think that somehow, in the case of mirror therapy,
the visual image is allowing the brain to reset any retained
memories of the detached limb,” he said.
Some quirky things about mirror therapy include the fact
that it doesn’t seem to work as well with just one finger but
has succeeded in patients missing a whole hand or foot.
Tsao knows that phantom breast pain occurs after mastectomy
but is unaware of anyone’s trying mirror therapy for this. For one
thing, it would have to be based on visualization but not move-
ment, since a breast cannot move independently, as a limb can.
The therapy even has worked for many patients whose
amputations occurred years ago and who have had phantom
pain since then.
Biggest Obstacle: Dissemination
In the case of mirror therapy, the obstacles are relatively
minor. As Tsao sees it, the only obstacle is disseminating
related to pain over the last few days or week, then the
study gets more exciting.”1
Tsao responded: “We measured pain daily at the begin-
ning of the session, so the pain score reflects the average
pain over the previous 24 hours.”
Moseley asked, “How did they remove bias? Reporting
bias is a big player in pain studies and could easily impart
reductions in pain of 30/100.”1
Tsao responded: “Subjects were recruited into the study by
being told that we were evaluating three therapies for phan-
tom limb pain (mirror, covered mirror, mental visualization)
to see if one of the therapies was best for relieving phantom
pain. Subjects reported their pain, number, and duration of
pain episodes each day prior to starting their therapy session.
“We believe that we did not bias subjects, especially
since we had subjects in both mental visualization and cov-
ered mirror groups tell us quite clearly that their phantom
pain was worsening while everyone in the mirror group
reported improvement,” he said.
References
1. Moseley L. The mirror cure for phantom pain. Scientific American,
April 16, 2008. Available at: www.sciam.com/article.cfm?id=the-
mirror-cure.
2. Chan BL, Witt R, Charrow AP, et al. Mirror therapy for phantom
limb pain. N Engl J Med 2007;357(21):2206–2207.
9
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Topics in Pain Management
the information. “A lot of people just don’t know about it,”
he said. “That’s the primary limitation.”
How do people hear about it? Tsao said not very many people
responded directly after the results of his study were published
as a correspondence in the New England Journal of Medicine.
“Usually, I hear from people after there is an article in
publications such as [TPM],” he said. “I’ve heard from very
few people who actually read the original article. It’s when
the mainstream media started picking it up that I began see-
ing more and more e-mails and calls.”
Tsao sends out the PowerPoint slides freely because he
thinks the therapy is easy for any practitioner to carry out.
In some cases, he has e-mailed the instructions to patients,
and they have e-mailed him back to say, “My pain is gone.”
“Those slides that we give out are pretty much the instruc-
tions on what you need to do,” Tsao said.
Grief Reaction to Sudden Visualization of a
Lost Limb
He said practitioners should be aware that patients initially
may have an emotional reaction of grief when they see what
appears to be their old limb in the mirror, whole and still
attached. Two of Tsao’s patients broke down crying.
However, those reactions lasted only about 2 minutes. “After
that initial reaction, they recovered and gave it a try,” he said.
Background in Pain and Cognitive Neurology
Tsao’s training is in clinical neurology and behavioral and
cognitive neurology. He has been at the Uniformed
Services University for 4 years. His clinical practice is at
Walter Reed and the National Naval Medical Center.
“I read Ramachandran’s paper on mirror therapy for phan-
tom limb pain when I was in graduate school,” Tsao said. “I
Instructions for Mirror Therapy for Patients With an
Amputated Foot or Leg
Patients in the clinical trial by Chan et al.,1 according to
corresponding author Jack Tsao, MD, DPhil, were to:
1. Place a mirror between their legs so that the reflecting
side faces the intact leg.
2. Move the intact foot very slowly while viewing the
image of it in the mirror and simultaneously going
through the mental process that would move the ampu-
tated (or phantom) foot in the same way as the foot seen
in the mirror. Plantar flexion and extension (bending the
foot up and down at the ankle similar to stepping on a
gas pedal) and foot rotation at the ankle (making cir-
cles) are the easiest movements.
10
December 2008
thought, ‘Wow, that’s interesting. I wonder why it works,’
and then thought nothing more about it.
“But when I arrived in DC, the war casualties had just
increased,” he said. “We were getting more and more
amputees at the hospital. There was a call for proposals for
research projects to try to address some of the issues facing
the returning soldiers. And, of course, phantom pain is one
of the main health conditions that diminishes the quality of
life and interferes with rehabilitation. It was a very critical
area, especially because not many therapies were available.
“So we put in a proposal to conduct a clinical trial to test
whether mirror therapy would relieve phantom pain,” Tsao
said. “There was no resistance at all (from his superiors and
colleagues at Walter Reed),” he said. “In fact, they were
quite positive about it.
“At that time, there had been no controlled study of mirror
therapy,” Tsao continued. “Because of the large numbers of
amputees that we are seeing here at Walter Reed, we felt we
could adequately test Ramachandran’s mirror therapy. We
hoped the results would give us something to offer to
amputees. But if not, we would put that whole theory to rest.”
Obviously, the outcome did not put mirror therapy to rest. I
References
1. Chan BL, Witt R, Charrow AP, et al. Mirror therapy for phantom
limb pain. N Engl J Med 2007;357:2206–2207.
2. Ramachandran VS, Rogers-Ramachandran D. Synaesthesia in
phantom limbs induced with mirrors. Proc Biol Sci 1996;263:
377–386.
3. Ramachandran VS, Hirstein W. The perception of phantom limbs.
Brain 1998;121:1603–1630.
3. Vary the movement speed of the intact foot once the
patient experiences a sensation of movement of the phan-
tom keeping time with what the subject sees in the mirror.
4. Measure visual analog scale pain score, number, and
duration of episodes in the past 24 hours before each day’s
therapy to track the subject’s response to mirror therapy.
5. Carry out 15 minutes of daily mirror therapy for 5 days
each week for at least 4 weeks.
Reference
1. Chan BL, Witt R, Charrow AP, et al. Mirror therapy for phantom
limb pain. N Engl J Med 2007;357:2206–2207.
©2008 Lippincott Williams & Wilkins, 800-787-8981
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Topics in Pain Management
Topics in Pain Management CME Quiz
To earn CME credit, you must read the CME article and
complete the quiz and evaluation assessment survey on the
enclosed form, answering at least 70% of the quiz questions
correctly. Select the best answer and use a blue or black pen
to completely fill in the corresponding box on the enclosed
answer form. Please indicate any name and address changes
directly on the answer form. If your name and address do
not appear on the answer form, please print that information
in the blank space at the top left of the page. Make a photo-
copy of the completed answer form for your own files and
mail the original answer form in the enclosed postage-paid
business reply envelope. Your answer form must be received
by Lippincott CME Institute, Inc., by November 30, 2009.
Only two entries will be considered for credit.
Online quiz instructions: To take the quiz online, go to
http://cme.LWWnewsletters.com, and enter your username
1. The International Headache Society defines occipital
neuralgia (ON) as a paroxysmal, sharp pain in the dis-
tribution of the lesser or greater occipital nerve with
associated paresthesia or dysesthesia in the same region.
A. True
B. False
2. All of the following statements regarding the anatomy
of the greater occipital nerve are true, except
A. It is formed by the medial branch of the dorsal ramus of
C2 that runs between the posterior arch of the atlas and
lamina of the axis.
B. It ascends between the inferior oblique and the semi-
spinalis capitis muscles.
C. It pierces the semispinalis capitis muscle and the
trapezius muscle (adjacent to their insertion into the
occipital bone between the superior and inferior nuchal
lines) to run along the occipital artery.
D. It is lateral to the occipital artery.
3. Structural causes of ON include all the following, except
A. direct trauma to the greater or lesser occipital nerves
B. compression of the greater or lesser occipital nerve or
the C2 or C3 nerve roots by degenerative cervical spine
changes
C. mid-thoracic disc disease
D. metastatic tumors affecting the C2 and C3 nerve roots
4. Few patients with ON report a cycle of pain-spasm-pain.
A. True
B. False
5. All the following conservative modalities to treat ON
have been reported in the literature as efficacious, except
A. physical therapy
B. massage
C. cold packs
D. acupuncture
©2008 Lippincott Williams & Wilkins, 800-787-8981
December 2008
and password. Your username will be the letters LWW (case
sensitive) followed by the 12-digit account number on your
mailing label. You may also find your account number on
the paper answer form mailed with your issue. Your pass-
word will be 1234; this password may not be changed.
Follow the instructions on the site. You may print your offi-
cial certificate immediately. Please note: Lippincott CME
Institute, Inc. will not mail certificates to online participants.
Lippincott Continuing Medical Education Institute, Inc., is
accredited by the Accreditation Council for Continuing Medical
Education to provide continuing medical education for physicians.
Lippincott Continuing Medical Education Institute, Inc., desig-
nates this educational activity for a maximum of 1.5 AMA PRA
Category 1 Credits™. Physicians should only claim credit com-
mensurate with the extent of their participation in the activity.
6. Medications that may help relieve pain in patients with
ON include all of the following, except
A. gabapentin 300–3600 mg/day
B. pregabalin 150–600 mg /day
C. thiopentone 300 mg/day
D. baclofen 40–120 mg/day
7. Surgical implantation of a subcutaneous electrode
along the C1–C3 nerve level has been shown to signifi-
cantly reduce the pain of ON in patients who have
failed conservative therapies.
A. True
B. False
8. CT fluoroscopy-guided nerve block is routinely per-
formed with deep anesthesia or sedation.
A. True
B. False
9. Selective C2 and/or C3 dorsal rhizotomy is a surgical
option for treatment of ON, although few published
papers have assessed its utility.
A. True
B. False
10. It has been postulated that a successful temporary per-
cutaneous lead trial, in combination with a previously
documented successful diagnostic occipital nerve block,
can predict a highly effective permanent occipital
nerve stimulator implantation.
A. True
B. False
11
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Topics in Pain Management
NEWS IN BRIEF
Medtronic Recalls Intrathecal
Catheters and Revision Kits
Medtronic Neuromodulation (Minneapolis, MN) noti-
fied health care professionals on October 2, 2008, of a
recall of several Medtronic intrathecal catheters and
intrathecal catheter revision kits. This has been classified
as a class I recall by the FDA.
Class I recalls are the most serious type of recall. This
classification is reserved for situations in which there is a
reasonable probability that use of the product will cause
serious injury or death.
The recalled catheters and revision kits are:
• Medtronic Neuromodulation Indura One-Piece Intrathecal
Catheter, model 8709SC;
• Medtronic Intrathecal Catheter, model 8731SC;
• Medtronic Sutureless Pump Connector Revision Kit,
model 8578; and
• Medtronic Intrathecal Catheter Pump Segment
Revision Kit, model 8596SC.
These catheters and revision kits are made for use with
the implanted Medtronic SyncroMed II, SynchroMed EL,
and IsoMed infusion pumps that store and deliver par-
enteral drugs to the intrathecal space. They were still in dis-
tribution at the time of the recall and were manufactured
beginning on November 21, 2006, until the time of the
recall, and were distributed beginning January 22, 2007.
This recall does not include the Medtronic MiniMed
infusion pumps.
Medtronic had first sent notices to health care professionals
in June describing the problem, according to the FDA website.
“The products were recalled because of potential mis-
connections of the Medtronic Sutureless Connector
Catheters from the catheter port on the pump,” according
to the October recall notice on the FDA website. “These
misconnections have resulted in a blockage between the
sutureless pump connector and the catheter port on the
pump and disconnection from the pump connector.”
In June, Medtronic had recommended that practitioners:
1. Verify cerebrospinal fluid backflow through the catheter;
2. Ensure alignment of the sutureless connector to the pump;
3. Snap the sutureless connector into place;
12
December 2008
4. Tug and rotate to test the connection;
5. Follow recommendations for managing patients with
implanted SC catheters; and
6. Provide ongoing education of patients and caregivers of the
signs and symptoms of drug underdose and withdrawal.
Professionals with questions should contact Medtronic at
800-328-0810, Monday–Friday, 8 a.m. to 5 p.m. central
daylight time.
To read the full recall and the recommendations for
health care professionals, see www.fda.gov/cdrh/recalls/
recall-062608.html. The entire 2008 MedWatch Safety
Summary, including a link to the class I recall notice, is
available at: www.fda.gov/medwatch/safety/2008/safety08.
htm#INDURA. I
New RF Generator Treats Four
Lesions Simultaneously
A new radiofrequency (RF) generator introduced by Stryker
Interventional Spine (Stryker Instruments, Kalamazoo, MI)
touts the ability to treat four lesions simultaneously, cutting
the treatment time from 15 minutes to about 5 minutes.
With the MultiGen, the practitioner can treat a much
broader strip of lesions instead of having to reposition the
probing each time. It allows the treatment of up to 4
lesions simultaneously, with independent control for each.
RF energy can be delivered with different starting times
for each lesion. Bipolar and monopolar procedures can be
performed at the same time; thermal and pulsed proce-
dures also can be performed at the same time.
The device can be used for facet denervation, medial
branch rhizotomy, sacroiliac denervation, percutaneous
chordotomy, dorsal root entry zone lesions, peripheral
neuralgia, trigeminal neuralgia, and ramus communicans.
The generator also has a full-touch screen with a hand-
held control. It can be used in a sterile environment.I
Coming Soon
• Pain Management of the Patient With Thoracic Disc
Herniation
• Management of Burn Pain
©2008 Lippincott Williams & Wilkins, 800-787-8981